IFD Safety Division – Mass/Environmental Exposure

Use this form to report non-blood borne pathogen exposures for groups of people and environmental reasons.

Date of Exposure*
MM slash DD slash YYYY
Incident Commander*
Incident Commander Email*
Battalion*
Shift*
Run Number*
Dispatch Time*

: Hours

Minutes
List Apparatus Involved in the Exposure
List Names of Individuals Exposed in this Incident
Business Name (Optional)
Location*
Street Address Address Line 2 City State ZIP / Postal Code Country
Was this an assault? Describe in the Summary.
- Assault
- No
Summary of Incident & Reason for Documentation. If you know names of specific chemicals involved, add in this summary.*

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